What is the medical management of conjunctivitis (pink eye)?

Medical Management of Conjunctivitis (Pink Eye)

Conjunctivitis should be classified by type (viral, bacterial, or allergic) before initiating appropriate treatment, as each requires different management approaches. 1

Diagnosis and Classification

Key Diagnostic Features

• Viral conjunctivitis: Watery discharge, often bilateral, preauricular lymphadenopathy, associated with upper respiratory symptoms
• Bacterial conjunctivitis: Purulent or mucopurulent discharge, matting of eyelids, conjunctival injection
• Allergic conjunctivitis: Intense itching, chemosis, watery discharge, often bilateral

History Elements to Assess

• Duration and time course of symptoms
• Character of discharge (watery, mucoid, purulent)
• Unilateral vs. bilateral presentation
• Associated symptoms (itching, pain, photophobia)
• Recent exposure to infected individuals
• Contact lens wear and hygiene
• Allergy history
• Recent trauma or surgery 2

Treatment Approach

Viral Conjunctivitis

• Primary treatment: Supportive care
  • Artificial tears for comfort
  • Cold compresses to reduce inflammation
  • Strict hygiene measures to prevent spread 1
• Usually self-limiting within 1-2 weeks
• No antibiotics needed (ineffective against viruses) 2

Bacterial Conjunctivitis

• First-line treatment: Topical broad-spectrum antibiotics for 5-7 days 1
  • Options include:
    • Polymyxin B-trimethoprim ophthalmic solution
    • Gentamicin ophthalmic solution
    • Moxifloxacin 0.5% ophthalmic solution
    • Bacitracin ophthalmic ointment 1-3 times daily 3
    • Erythromycin ophthalmic ointment 4
• Application: Apply directly to conjunctival sac
• Duration: Continue for 24-48 hours after symptoms resolve
• Note: Many cases (41%) resolve without antibiotics by days 6-10, but treatment speeds resolution and reduces transmission 1
• For mild cases: Delayed antibiotic prescribing may be considered 1, 5
• Adjunctive measures:
  • Warm compresses (preferred over cold) to soften discharge and loosen crusts 1
  • Frequent handwashing and hygiene measures 1

Allergic Conjunctivitis

• First-line treatment: Topical antihistamines with mast cell-stabilizing activity 1, 6
• Adjunctive measures:
  • Cold compresses
  • Artificial tears
  • Allergen avoidance 7

Special Cases

Gonococcal Conjunctivitis

• Requires both systemic and topical therapy
• Systemic treatment with ceftriaxone 1

Chlamydial Conjunctivitis

• Requires systemic therapy with:
  • Azithromycin
  • Doxycycline
  • Levofloxacin 1

Neonatal Conjunctivitis

• Immediate referral to ophthalmologist
• Prophylaxis with erythromycin ophthalmic ointment for prevention of ophthalmia neonatorum 4
• Treatment based on onset timing:
  • 1-7 days: Consider gonococcal infection
  • 5-19 days: Consider chlamydial infection
  • First week: Common bacterial infection 1

Prevention and Control

• Frequent handwashing
• Avoid touching or rubbing eyes
• Use separate towels and washcloths
• Avoid sharing pillowcases
• Proper disinfection of toys and surfaces 1
• For contact lens wearers:
  • Discontinue lens wear until infection resolves
  • Replace lenses after resolution 1

Indications for Ophthalmology Referral

Refer patients with:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• No response to therapy after 3-4 days
• History of herpes simplex virus eye disease
• Immunocompromised status
• All cases of neonatal conjunctivitis 1

Important Caveats

• Indiscriminate use of antibiotics should be avoided as viral conjunctivitis will not respond to antibacterial agents 2
• Never use corticosteroid-containing products unless proven to be non-herpetic 8
• Consider local antibiotic resistance patterns when selecting treatment 1
• Dilute bleach solution (1:10) is recommended for disinfecting tonometers and surfaces 2, 1